Pubdate: Mon, 31 Dec 2001
Source: Providence Journal, The (RI)
Copyright: 2001 The Providence Journal Company
Contact:  http://www.projo.com/
Details: http://www.mapinc.org/media/352
Author: Stanley M. Aronson
Note: Stanley M. Aronson, M.D., a weekly contributor, is dean of medicine 
emeritus, Brown University.

THE CURSE OF THE POPPY BLOSSOM

Opium, the congealed sap of the poppy plant, has been both a blessing and a 
curse to mankind since its discovery some four millennia ago. The ancient 
Sumerians called it Hul Gil (the joy plant) and taught its harvesting 
methods to the Assyrians who in turn shared it with the Babylonians and 
Egyptians. For countless centuries opium has lessened pain, induced sleep 
and soothed the troubled spirits of those in emotional turmoil. But for 
those who used it more than briefly it might also result in a tenacious 
state of dependency. And despite claims otherwise, it numbed the creative 
talents of those addicted to its euphoric effects. On a larger scale, opium 
prompted a series of wars in 19th-century Asia. Top Opinion stories:

In 1803, the German chemist Friedrich Sertuerner isolated one of the active 
ingredients of opium sap, calling it Principium somniferum, and later, 
morphine, named after Morpheus, the Roman god of dreams and the son of 
Hypnos. Morphine represented a major advance as a therapeutic agent for two 
reasons: First, as a pure alkaloid it could now be administered in precise 
amounts (opium sap, on the other hand, varied in narcotic strength from 
batch to batch). And second, in contrast to opium, morphine was soluble in 
water and hence could be injected into the body, thus achieving virtually 
instantaneous pharmacological effects such as pain suppression.

The great promise of morphine had been fulfilled: It was cheap, produced 
its effects rapidly and was much safer than opium. By 1827, E. Merck of 
Darmstadt, Germany, began the commercial manufacture of morphine. But it 
did not take long for physicians to appreciate that morphine also generated 
habituation, dependency and finally addiction.

An appeal was made to the many creative organic chemists of 19th- century 
Germany: Can an opiate alkaloid be isolated -- or synthesized from raw 
opium while still retaining its analgesic (pain-killing) and narcotic 
powers, preserving its rapid and short-acting attributes, causing no 
troublesome side-effects and, most important, provoking no chemical dependency?

In 1895, the German chemist Heinrich Dreser, working for the Bayer Company, 
modified the chemical structure of morphine, producing a highly potent 
narcotic which was initially thought to produce little addiction. The 
product went into production and was first known as diacetylmorphine but 
later called heroin. The British initially used heroin, in decreasing 
doses, to treat opium addiction. But by 1903, heroin addiction had risen to 
alarming proportions, particularly in the United States and the dream of a 
nonaddicting opiate had vanished.

The search continued for a potent opiate that was essentially free of 
addictive tendencies and avoided the nightmare of withdrawal symptoms. 
During World War II, Germany had a shortage of medicinal morphine. And in 
response to this, I.G. Farben developed a synthetic alternative originally 
called adolfine (allegedly named to honor Adolf Hitler) but then named 
dolofine. It is more likely that the name was coined from the Latin, dolor 
(pain) and finis (end). The German pharmacologists were especially 
impressed with the ability of this compound to reduce pathological spasms 
of internal organs.

U.S. public health officials were seeking an opiate that might lessen the 
intolerable discomfort of deliberate heroin withdrawal; and in 1950, they 
included dolofine in their clinical trials. The chemical name for dolofine 
was methaminodiphenylone; and following the American penchancy for 
acronyms, they shortened the name to methadone.

In the early 1950s, Dr. Vincent Dole and his colleagues found that a single 
daily oral dose of methadone, in heroin addicts, was sufficient to prevent 
both the craving for narcotics and the withdrawal symptomatology.

Admittedly, these clinic patients were now irreversibly addicted to 
methadone, but at least they were able to maintain jobs and avoid the 
roller-coaster phenomenon of heroin dependency. Those who condemned the 
methadone clinics claimed that they achieved little more than substitute 
one addiction for another. But the advocates of methadone replacement 
therapy declared that this therapy is inexpensive, has few significant 
side-effects and permits its users to lead crime-free, productive lives 
with little motivation to seek heroin. Currently there are, in this nation, 
more than 100,000 individuals on oral methadone replacement therapy.

Yet another recently developed opiate-like narcotic is oxycondone that, 
when, properly administered, is a powerful agent capable of suppressing 
pains generated by cancer or injury.

In January 2001, newspaper reports described a crime-wave ascribed to the 
stealing and trafficking of oxycondone supplies both from pharmacies, 
nursing homes and even from the medicine chests of individuals legally in 
possession of these agents. One of the most popular of the oxycondones is a 
medication called OxyContin. Each tablet of this drug is covered by a 
substance which regulates the measured release of the underlying narcotic 
during a 12-hour interval. Many patients can thus obtain uninterrupted pain 
relief with only two oral tablets each day. And many are convinced that 
OxyContin suppresses pain more effectively than any of the other opiates.

Addicts quickly learned that when the outer coating of OxyContin is 
removed, they are left with an very powerful narcotic that can be easily 
administered intravenously, achieving a rapid and somewhat sustained high. 
OxyContin became the street drug of choice in smaller Appalachian and 
Midwest communities particularly where heroin was not readily available.

A number of deaths have been associated with the illegal use of OxyContin; 
but in most of these cases there was concurrent abuse of alcohol and other 
illicit substances.

A recent analysis of drug-related emergency room visits shows a clear 
increase in visits occasioned by adverse effects of OxyContin abuse. Last 
year, there were an estimated 10,400 such visits nationwide. But to keep 
this is the context of overall drug abuse, there were, during that same 
interval, 187,000 emergency room visits prompted by cocaine usage. A 1999 
National Household Survey on Drug Abuse showed that about 9 percent of the 
American public (19.9 million people), on one or more occasions, had used 
illegally obtained pain-killers.

The search for new opiates continues. But given the uncritical enthusiasm 
that greeted prior opiate candidates, it would be prudent to regard each 
newly arrived drug with a substantial measure of caution.
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MAP posted-by: Jay Bergstrom